OFFICE OF THE DY.

COMMISSIONER OF POLICE SPECIAL BRANCH (I),

C.I.D., MUMBAI
Personal Particulars Form
(1)

Name in full ( IN BLOCK LETTER ) with

SURNAME
NAME
aliases if any
.
laiw.kZ uko izFke vkMuko

(2)

Present Address in full

l/;kpk laiw.kZ iRrk

(3)

Home Address in full (i.e. Village, Thana, .

Taluka/ Tahsil and District or House No. .
Lane/Street/Road and town alongwith pin
code.)
xkokpk iw.kZ iRrk vFkkZr xko] Bk.ks] rkyqdk] ftYgk
rlsp ?kj ua- xYyh@ysu@jLrk vkf.k ihu dksM ua

(4)

Particulars of the places (with period of

residence) where you have resided during
preceding years since birth.
;k iwohZ vki.k jgkr vlysY;k tkxspk iw.kZ iRrk o
dkyko/kh tUekiklwu

(5)

Information
ekfgrh

Name
uko

(i)

From .to..
iklwu --------------------------------rs---------------------iRrk %
-----------------------------------------(ii) .
(iii) .
Occupation with address
O;olk; o iRrk

Present address
l/;kpk iRrk

(i)

Father
oMhy

...
...

(ii)

Mother
vkbZ

...
...

(iii) Husband/ Wife ...

irh@iRuh
...
(iv) Brother
Hkk

...
...

(v)

...
...

Sister
cgh.k

(6)

Date of birth and present age ..

tUe rkjh[k o l/;kps o;

(7)

Place of birth ( full address )

tUeLFkku iw.kZ iRrk

(8)

Education qualification showing places of (i)

(ii)
education with year in school/colleges.
Date of
Date of
entering
leaving
izos'kkph rkjh[k
lksMY;kph rkjh[k
(iv)
Name and address of
school/college.
'kkGk@egkfon;ky;kpk iRrk
(i)

.
.

(ii)
(iii)
(iv)
(G.C.P.) K 1980 (50,000&2-06)

(iii)
Examination
passed
dks.krh ijh{kk ikl dsyh

(2)

(9)

Have you ever been arrested/prosecuted/ detained/

fined/convicted? If so, give particulars of the case
vki.kkl d/kh vVd >kyh gksrh@[kVyk pkyyk
gksrk@LFkkuc/n dsys gksrs@naM >kyk gksrk fdaok dksVkZr
f'k{kk >kyh gksrh dk;\ vlY;kl dslph ekfgrh FkksMD;kr
fygk-

(10) Have you ever taken active part in politics ? If so,

give particulars.
vki.k d/kh jktdkj.kkr lf; Hkkx ?ksryk vkgs dk; \
vlY;kl ri'khy n;kok(11) Present occupation/service with all particulars
l/;kpk vkiyk /kank@uksdjh o R;kpk iw.kZ ri'khy
(12) Reasoning for obtaining character and antecedent
certificate and to whom it is required.
pkfj; iMrkG.kh o iwoZ bfrgkl vgoky d'kkdfjrk
ikfgts vkgs o dks.kR;k fBdk.kh \
(13) Identification Mark
vksG[k fpUg
(14) Names, addresses and signatures of the two (1)
responsible persons of your locality to whom you
are known
vkiY;k Hkkxkrhy vki.kkal vksG[k.kk;k nksu lnx`gLFkkaph (2)
ukaos] laiw.kZ iRrk o Lok{kjh-

I certify that the forgoing information is correct and complete to the best of my knowledge and belief
eh vls izek.ki= tkghj djrks dh] ojhy uewn dsysyh ekfgrh gh ek;k lakax.;kuqlkj o fo'oklkizek.ks vpwd vkf.k iw.kZ vkgs-

Place :
tkxk %
Signature of the applicant
vtZnkjkph Lok{kjh

Date :
fnukad %
Note -

Applicant should attach the following alongwith the application :(1) A demand draft of Rs. 100 in the name of Commissioner of Police, Brihan Mumbai
(2) Two passport size photographs.
(3) Xerox copy of ration card showing applicant's name and address.
(4) Xerox copy of the school leaving certificate.
(5) Xerox copy of the passport (if any).
(6) Demanding letter from Company/Institution.

lwpuk -

vtZnkjkus vtkZlkscr [kkyhy uewn dsysyh lgi=s tksMkohr %&

1

iksyhl vk;qDr] c`gUeqacbZ ;kaps ukos 100 :Ik;kapk cWadspk fMekaM MkV

2 ikliksVZ lkbZtps nksu QksVks

3 js'ku dkMkZph vtZnkjkps uko o iRrk vlysyh >sjkWDl izr4 'kkGk lksMY;kP;k nk[kY;kph >sjkWDl izr5 ikliksVZ vlY;kl] R;kP;k ifgY;k nksu ikukaph >sjkWDl izr6 daiuh @laLFkk ;kaps pkfj; iMrkG.kh ekx.khi=